Fundamentals of Nursing - Chapter 12 - Client Safety PDF

CHAPTER 12 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT FALLS SECTION: SAFETY AND INFECTION CONTROL Older adult clients can be at an incr...

CHAPTER 12 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT FALLS SECTION: SAFETY AND INFECTION CONTROL Older adult clients can be at an increased risk for falls Client Safety due to decreased strength, impaired mobility and CHAPTER 12 balance, improper use of mobility aids, unsafe clothing, environmental hazards, endurance limitations, and decreased sensory perception. Safety is freedom from injury. Providing for Other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary safety and preventing injury are major nursing frequency, gait and balance problems (cerebral palsy, responsibilities. injury, multiple sclerosis), and cognitive dysfunction. Adverse effects of medications (orthostatic hypotension, Many factors affect clients’ ability to protect drowsiness) can also increase the risk for falls. Clients are at greater risk for falls when they have more themselves. Those factors include the client’s than one risk factor. age, with the young and old at greater risk; Prevention of client falls is a major nursing priority. Nurses must evaluate all clients in health care facilities mobility; cognitive and sensory awareness; for risk factors for falls and implement preventative emotional state; ability to communicate; and measures accordingly. Programs to prevent falls are essential for settings that lifestyle and safety awareness. provide services to older adult clients. Health care facilities must actively prevent falls, It is the provider’s responsibility to assess, especially because Medicare and Medicaid no longer report, and document clients’ allergies and to reimburse for treating injuries resulting from falls. provide care that avoids exposure to allergens. PREVENTING FALLS Complete a fall‑risk assessment for each client at NURSING ACTIONS admission and at regular intervals. Individualize the Use risk assessment tools to evaluate clients and their plan for each client according to the results of the environment for safety. fall‑risk assessment. For example, instruct a client who Encourage clients to speak up and take an active role in has orthostatic hypotension to avoid getting up too their health care and in preventing errors. quickly, to sit on the side of the bed for a few seconds Create a culture of checks and balances to avoid errors prior to standing, and to stand at the side of the bed for when working in stressful circumstances. a few seconds prior to walking. Communicate risk factors and plans of care to clients, Be sure the client knows how to use the call light (by family, and other staff. giving a return demonstration), that it is in reach, and Use protocols for responding to dangerous situations. to encourage its use. Adopt quality care priorities from the National Quality Respond to call lights in a timely manner. Forum, including “Never Events.” Use fall‑risk alerts (color‑coded wristbands). Use current evidence to promote a culture of safety, Provide regular toileting and orientation of clients who while using the National Patient Safety Goals as a guide. have cognitive impairment. Know the facility’s disaster plan, understand the chain Provide adequate lighting. of command and roles, and use common terminology Orient clients to the setting to make sure they know when communicating with the team. how to use all assistive devices (grab bars) and can Identify and document incidents and responses according locate necessary items. to the facility’s policy. These reports help identify trends, Place clients at risk for falls near the nurses’ station. patterns, and the root cause of adverse events. Provide hourly rounding. Know the location of safety data sheets and hazardous Make sure’ bedside tables, overbed tables, and chemicals in the environment. frequent‑use items (telephone, water, facial tissues) are Use equipment only after adequate instruction and within reach. safety inspection. Keep the bed in the low position and lock the brakes. For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up. Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance. Provide nonskid footwear and nonskid bath mats for use in tubs and showers. Use gait belts and additional safety equipment when moving clients. Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture). FUNDAMENTALS FOR NURSING CHAPTER 12 Client Safety 59  Keep assistive devices nearby after validation of safe use SECLUSION AND RESTRAINT (eyeglasses, walkers, transfer devices). Nurses must know and follow federal, state, and facility Educate the client and family about safety risks and the policies for the use of restraints. plan of care. Clients and family who are aware of risks are Some clients require seclusion rooms and/or restraints. more likely to call for assistance. In general, use seclusion or restraints for the shortest Lock the wheels on beds, wheelchairs, and carts to prevent duration necessary and only if less restrictive measures them from rolling during transfers or stops. are not sufficient. They are for the physical protection of Use electronic safety monitoring devices (chair or bed the client or the protection of other clients or staff. sensors) for clients at risk for getting up without assistance Clients can voluntarily request temporary seclusion if to alert staff of independent ambulation. the environment is disturbing or seems too stimulating. Report and document all incidents. This provides valuable Restraints can be either physical (devices that restrict information that can help prevent similar incidents. movement: vest, belt, mitt, limb) or chemical (sedatives, neuroleptic or psychotropic medications) to calm the client. SEIZURES Restraints can cause complications, including A seizure is a sudden surge of electrical activity in the brain. pneumonia, incontinence, and pressure injuries. It can occur at any time due to epilepsy, fever, or a variety It is inappropriate to use seclusion or restraints for: of medical problems. Partial seizures (also called focal ◯ Convenience of the staff seizures) are due to electrical surges in one hemisphere ◯ Punishment for the client of the brain, and generalized seizures involve both ◯ Clients who are extremely physically or hemispheres of the brain. Status epilepticus (a prolonged mentally unstable seizure) is a medical emergency. ◯ Clients who cannot tolerate the decreased stimulation of a seclusion room Restraints should: SEIZURE PRECAUTIONS ◯ Never interfere with treatment Seizure precautions (measures to protect clients from ◯ Restrict movement as little as is necessary injury during a seizure) are imperative for clients who ◯ Fit properly and be as discreet as possible have a history of seizures that involve the entire body ◯ Be easy to remove or change and/or result in unconsciousness. When all other less restrictive means have failed to Make sure rescue equipment is at the bedside, including prevent a client from harming themselves or others oxygen, an oral airway, suction equipment, and padding for (orientation to the environment, supervision of a family the side rails. Clients at high risk for generalized seizures member or sitter, diversional activities, electronic should have a saline lock in place for immediate IV access. devices), the following must occur before using Ensure rapid intervention to maintain airway patency. seclusion or restraints. Inspect the client’s environment for items that could ◯ The provider must prescribe seclusion or restraints in cause injury during a seizure, and remove items that are writing, after a face‑to‑face assessment of the client. not necessary for current treatment. Assist clients at risk for seizures with ambulation and In an emergency situation when there is immediate risk to the client or others, nurses can place transferring to reduce the risk of injury. Advise all caregivers and family not to put anything restraints on a client. The nurse must obtain a prescription from the provider as soon as possible in the client’s mouth (except an airway for status according to the facility’s policy (usually within 1 hr). epilepticus) during a seizure. Advise all caregivers and family not to restrain the client ◯ The prescription must include the reason for the during a seizure but to lower the client to the floor or restraints, the type of restraints, the location of the bed, protect their head, remove nearby furniture, provide restraints, how long to use the restraints, and the privacy, put them on one side with the head flexed type of behavior that warrants using the restraints. slightly forward if possible, and loosen their clothing. ◯ The prescription allows only 4 hr of restraints for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Providers DURING A SEIZURE can renew these prescriptions with a maximum of Stay with the client, and call for help. 24 consecutive hours. Maintain airway patency and suction PRN. ◯ Providers cannot write PRN prescriptions Administer medications. for restraints. Note the duration of the seizure and the sequence and type of movements. After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery. Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider. 60 CHAPTER 12 Client Safety CONTENT MASTERY SERIES  NURSING RESPONSIBILITIES FOR FIRE SAFETY CLIENTS IN RESTRAINTS Fires in health care facilities are usually due to problems Explain the need for the restraints to the client and with electrical or anesthetic equipment, or from smoking. family, emphasizing that the restraints keep the client All staff must: safe and are temporary. Know the location of exits, alarms, fire extinguishers, Ask the client or guardian to sign a consent form. and oxygen shut‑off valves. Review the manufacturer’s instructions for Make sure equipment does not block fire doors. correct application. Know the evacuation plan for the unit and the facility. ◯ Assess skin integrity, and provide skin care according to the facility’s protocol, usually every 2 hr. Fire response follows the RACE sequence ◯ Offer food and fluid. ◯ Provide a means for hygiene and elimination. R: Rescueand protect clients in close proximity to the ◯ Monitor vital signs. fire by moving them to a safer location. Clients who are ◯ Offer range‑of‑motion exercises of extremities. ambulatory can walk independently to a safe location. Pad bony prominences to prevent skin breakdown. A: Alarm:Activate the facility’s alarm system and then Secure restraints to a movable part of the bed frame. If report the fire’s details and location. restraints with a buckle strap are not available, use a quick-release knot to tie the strap. C: Contain/Confinethe fire by closing doors and windows Make sure the restraints are loose enough for range of and turning off any sources of oxygen and any electrical motion and that there is enough room to fit two fingers devices. Ventilate clients who are on life support with a between the restraints and the client. bag‑valve mask. Remove or replace restraints frequently to ensure good E: Extinguishthe fire if possible using the appropriate fire circulation to the area and allow for full range of motion extinguisher. to the limbs. Conduct an ongoing evaluation of the client. Regularly determine the need to continue using FIRE EXTINGUISHERS the restraints. To use a fire extinguisher, use the PASS sequence. Never leave the client alone without the restraints. Check facility policy regarding types of restraints. Many P: Pullthe pin. facilities no longer use vest restraints due to the risk A: Aimat the base of the fire. for strangulation. S: Squeezethe handle. DOCUMENT S: Sweepthe extinguisher from side to side, covering the area of the fire. Precipitating events and behavior of the client prior to seclusion or restraints Classes of fire extinguishers Alternative actions to avoid seclusion or restraints Time of application and removal of the restraints Class Ais for combustibles (paper, wood, upholstery, rags, Type of restraints and location other types of trash fires). The client’s behavior while in restraints Class Bis for flammable liquids and gas fires. Type and frequency of care (range of motion, neurologic checks, removal, integumentary checks) Class Cis for electrical fires. Condition of the body part in restraints The client’s response at removal of the restraints Medication administration FUNDAMENTALS FOR NURSING CHAPTER 12 Client Safety 61  Application Exercises Active Learning Scenario 1. A nurse is caring for a client who fell at a nursing A nurse educator is addressing the safe use of seclusion home. The client is oriented to person, place, and restraints with a group of newly licensed nurses. What and time and can follow directions. Which of the information should the nurse include? Use the ATI Active following actions should the nurse take to decrease Learning Template: Basic Concept to complete this item. the risk of another fall? (Select all that apply.) NURSING INTERVENTIONS: Describe at least A. Place a belt restraint on the client when they six nursing responsibilities when caring for a are sitting on the bedside commode. client in either seclusion or restraints. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client’s call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall‑risk assessment. 2. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. “I will place the client on their side.” B. “I will go to the nurses’ station for assistance.” C. “I will note the time that the seizure begins.” D. “I will prepare to insert an airway.” 3. A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. 4. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority? A. Complete a fall‑risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client’s environment. D. Make sure the client uses assistive aids in their possession. 5. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client’s room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client’s room. D. Place wet towels along the base of the door to the client’s room. 62 CHAPTER 12 Client Safety CONTENT MASTERY SERIES